Nelson Jr, Harry NEW YORK STATE DEPARTMENT OF HEALTH I S3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harry Robert Nelson Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 7, 2014 77 War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Deathrn
Esi Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
Gamal Khalifa, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Towra.or Vie ailtr►g / fk . z,,Q 1 3 r 8
❑Burial Date Cemetery or Crematory
August 15, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
illRemoval and/or Held
p and/or Address
H Hold
N Date Point of
p, ❑Transportation Shipment
_ by Common Destination
Cl Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
0
W
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Fr/i 5 l i g Registrar of Vital Statistics (t3ckn t,Ap
(si nature)
District Number 5(00\ Place 6UNN,cVCAiNS i 14
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 08/15/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2` (address)
W'
Ce (section)
lot number) (grave number)
0' Name of Sexton or Person in Charge of Premises •, �s- "
0
414
�� . (pl ase print)
W Signature �,/�..-T' Title O`MA
(over)
DOH-1555 (02/2004)